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Background Recent randomized trials have demonstrated the efficacy of mechanical thrombectomy in treating acute ischemic stroke, however, further research is required to optimize this technique. We aimed to evaluate the impact of guide catheter position and clot crossing on revascularization rates using A Direct Aspiration First Pass Technique (ADAPT). Methods Data were collected between January 2018 and August 2019 as part of the Spanish ADAPT Registry on ACE catheters (SARA), a multicenter observational study assessing real-world thrombectomy outcomes. Demographic, clinical, and angiographic data were collected. Subgroup analyses assessed the relationship between guide catheter/microguidewire position and modified Trombolysis in Cerebral Infarction (mTICI) scores. First pass effect (FPE) was defined as mTICI 3 after single pass of the device. Results From a total of 589 patients, 80.8% underwent frontline aspiration thrombectomy. The median score on the National Institutes of Health Stroke Scale (NIHSS) was 16.0. After adjusting for confounders, the likelihood of achieving FPE (adjusted Odds Ratio (aOR), 0.587; 95% confidence interval (CI), 0.38 to 0.92; p=0.0194) were higher among patients with more distal petrocavernous placement of guide catheter. The likelihood of achieving FPE (aOR, 0.592; 95% CI, 0.39 to 0.90; p=0.0138) and final angiogram complete reperfusion (aOR, 0.465; 95% CI, 0.30 to 0.73; p=0.0008) were higher among patients without microguidewire crossing the clot. No difference was noted for time from arterial puncture to reperfusion in any study group. At the 90-day follow-up, the mortality rate was 9.2% and 65.8% of patients across the entire study cohort were functionally independent (modified Rankin Scale (mRS) 0-2). Conclusions Petrocavernous guide catheter placement improved first-pass revascularization. Crossing the occlusion with a microguidewire lowered the likelihood of achieving FPE and complete reperfusion after final angiogram. [ABSTRACT FROM AUTHOR]

Background Flow diverters (FDs) have become an integral part of treatment for brain aneurysms. Aim To summarize available evidence of factors associated with aneurysm occlusion (AO) after treatment with a FD. Methods References were identified using the Nested Knowledge AutoLit semi-automated review platform between January 1, 2008 and August 26, 2022. The review focuses on preprocedural and postprocedural factors associated with AO identified in logistic regression analysis. Studies were included if they met the inclusion criteria of study details (ie, study design, sample size, location, (pre)treatment aneurysm details). Evidence levels were classified by variability and significancy across studies (eg, low variability ≥5 studies and significance in ≥60% throughout reports). Results Overall, 2.03% (95% CI 1.22 to 2.82; 24/1184) of screened studies met the inclusion criteria for predictors of AO based on logistic regression analysis. Predictors of AO with low variability in multivariable logistic regression analysis included aneurysm characteristics (aneurysm diameter), particularly complexity (absence of branch involvement) and younger patient age. Predictors of moderate evidence for AO included aneurysm characteristics (neck width), patient characteristics (absence of hypertension), procedural (adjunctive coiling) and post-deployment variables (longer follow-up; direct postprocedural satisfactory occlusion). Variables with a high variability in predicting AO following FD treatment were gender, FD as re-treatment strategy, and aneurysm morphology (eg, fusiform or blister). Conclusion Evidence of predictors for AO after FD treatment is sparse. Current literature suggests that absence of branch involvement, younger age, and aneurysm diameter have the highest impact on AO following FD treatment. Large studies investigating high-quality data with well-defined inclusion criteria are needed for greater insight into FD effectiveness. [ABSTRACT FROM AUTHOR]

Background Robotic-assisted neurointervention was recently introduced, with implications that it could be used to treat neurovascular diseases. Objective To evaluate the effectiveness and safety of the robotic-assisted platform CorPath GRX for treating cerebral aneurysms. Methods This prospective, international, multicenter study enrolled patients with brain aneurysms that required endovascular coiling and/or stent-assisted coiling. The primary effectiveness endpoint was defined as successful completion of the robotic-assisted endovascular procedure without any unplanned conversion to manual treatment with guidewire or microcatheter navigation, embolization coil(s) or intracranial stent(s) deployment, or an inability to navigate vessel anatomy. The primary safety endpoint included intraprocedural and periprocedural events. Results The study enrolled 117 patients (74.4% female) with mean age of 56.6 years from 10 international sites,. Headache was the most common presenting symptom in 40/117 (34.2%) subjects. Internal carotid artery was the most common location (34/122, 27.9%), and the mean aneurysm height and neck width were 5.7±2.6 mm and 3.5±1.4 mm, respectively. The overall procedure time was 117.3±47.3 min with 59.4±32.6 min robotic procedure time. Primary effectiveness was achieved in 110/117 (94%) subjects with seven subjects requiring conversion to manual for procedure completion. Only four primary safety events were recorded with two intraprocedural aneurysm ruptures and two strokes. A Raymond-Roy Classification Scale score of 1 was achieved in 71/110 (64.5%) subjects, and all subjects were discharged with a modified Rankin Scale score of ≤2. Conclusions This first-of-its-kind robotic-assisted neurovascular trial demonstrates the effectiveness and safety of the CorPath GRX System for endovascular embolization of cerebral aneurysm procedures. [ABSTRACT FROM AUTHOR]

Background: The neutrophil–lymphocyte ratio (NLR) is emerging as an important biomarker of acute physiologic stress in a myriad of medical conditions, and is a confirmed poor prognostic indicator in COVID-19. Objective: We sought to describe the role of NLR in predicting poor outcome in COVID-19 patients undergoing mechanical thrombectomy for acute ischemic stroke. Methods: We analyzed NLR in COVID-19 patients with large vessel occlusion (LVO) strokes enrolled into an international 12-center retrospective study of laboratory-confirmed COVID-19, consecutively admitted between March 1, 2020 and May 1, 2020. Increased NLR was defined as ≥7.2. Logistic regression models were generated. Results: Incidence of LVO stroke was 38/6698 (.57%). Mean age of patients was 62 years (range 27–87), and mortality rate was 30%. Age, sex, and ethnicity were not predictive of mortality. Elevated NLR and poor vessel recanalization (Thrombolysis in Cerebral Infarction (TICI) score of 1 or 2a) synergistically predicted poor outcome (likelihood ratio 11.65, p =.003). Patients with NLR > 7.2 were 6.8 times more likely to die (OR 6.8, CI95% 1.2–38.6, p =.03) and almost 8 times more likely to require prolonged invasive mechanical ventilation (OR 7.8, CI95% 1.2–52.4, p =.03). In a multivariate analysis, NLR > 7.2 predicted poor outcome even when controlling for the effect of low TICI score on poor outcome (NLR p =.043, TICI p =.070). Conclusions: We show elevated NLR in LVO patients with COVID-19 portends significantly worse outcomes and increased mortality regardless of recanalization status. Severe neuro-inflammatory stress response related to COVID-19 may negate the potential benefits of successful thrombectomy. [ABSTRACT FROM AUTHOR]

Background Flow diversion is an innovative and increasingly used technique for the treatment of intracranial aneurysms. New flow diverters (FDs) are being introduced to improve the safety and efficacy of this treatment. The aim of this study was to assess the safety, feasibility, and efficacy of the new Pipeline Vantage (PV) FD. Methods Patients with intracranial aneurysms treated with the PV at 10 international neurovascular centers were retrospectively analyzed. Patient and aneurysm characteristics, procedural parameters, complications, and the grade of occlusion were assessed. Results 60 patients with 70 aneurysms (5.0% with acute hemorrhage, 90.0% located in the anterior circulation) were included. 82 PVs were implanted in 61 treatment sessions. The PV could be successfully implanted in all treatments. Additional coiling was performed in 18.6%, and in- stent balloon angioplasty (to enhance the vessel wall apposition) in 24.6%. Periprocedural technical complications occurred in 24.6% of the treatments, were predominantly FD deployment problems, and were all asymptomatic. The overall symptomatic complication rate was 8.2% and the neurological symptomatic complication rate was 3.3%. Only one symptomatic complication was device- related (perforator artery infarctions leading to stroke). After a mean follow- up of 7.1 months, the rate of complete aneurysm occlusion was 77.9%. One patient (1.7%) died due to aneurysmal subarachnoid hemorrhage which occurred before treatment, unrelated to the procedure. Conclusions The new PV FD is safe and feasible for the treatment of intracranial aneurysms. The shortterm occlusion rates are promising but need further assessment in prospective long- term follow- up studies. [ABSTRACT FROM AUTHOR]

Background and purpose: Previous studies suggest that mechanisms and outcomes in patients with COVID‐19‐associated stroke differ from those in patients with non‐COVID‐19‐associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID‐19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors. Methods: A cross‐sectional, international multicenter retrospective study was conducted in consecutively admitted COVID‐19 patients with concomitant acute LVO, compared to a control group without COVID‐19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable‐adjusted analysis was conducted. Results: In this cohort of 697 patients with acute LVO, 302 had COVID‐19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID‐19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID‐19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23–0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12–0.77; p = 0.012). Moreover, endovascular complications, in‐hospital mortality, and length of hospital stay were significantly higher among COVID‐19 patients (p < 0.001). Conclusion: COVID‐19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID‐19 patients with LVO were more often younger and had higher morbidity/mortality rates. [ABSTRACT FROM AUTHOR]

Background: While Balloon Guide Catheters (BGC) have been shown to increase the rate of reperfusion during mechanical thrombectomy (MT), its implementation with transfemoral approach is at times limited due to unfavorable vascular anatomy. Objective: to determine safety, feasibility and performance of the transradial use of 8 F BGC Flowgate 2 during mechanical thrombectomy procedures in patients with unfavorable vascular anatomies (type 3 or bovine arch) Material/Methods: We performed a retrospective cohort study of consecutive transradial mechanical thrombectomies performed with BGC Flowgate 2 between January and December 2019. Patient demographics, procedural and radiographic metrics, and clinical data were analyzed. Results: 20 (8.7%) out of 230 overall thrombectomy procedures underwent transradial approach using an 8 F BGC Flowgate. 2 Successful approach was achieved in 17/20 cases, and in 3 cases radial was switched to femoral, after failure. TICI 2 C/3 was achieved in 18 cases (90%), followed by TICI 2 b and 2a in 1 (5%) case respectively. The average number of passes was 1.8. The average radial puncture-to-first pass time was 22 min. Radial vasospasm was observed in 3/20 cases. The Flowgate 2 was found kinked in 4/20 cases (20%), all of them during right internal carotid procedures. There were no postprocedural complications at puncture site, as hematoma, pseudoaneurysm or local ischemic events Conclusion: The use of 8 F Balloon Guide Catheter during MT via transradial approach might represent an alternative in selected cases with unfavorable vascular anatomies. Its use in right ICA catheterizations was associated with a high rate of catheter kinking. [ABSTRACT FROM AUTHOR]

Coil prolapse or migration is a rare but potentially serious complication that may occur during aneurysm embolization, with no standard management currently described. Here we describe our experience with the Embolus Retriever with Interlinked Cages (ERIC) device® (Microvention, Aliso Viejo, CA, USA) for the retrieval of prolapsed or migrated coils in a case series and Flow-Model analysis. First, a retrospective review was performed using our institution database for patients in which coil prolapse or migration occurred during aneurysm embolization, and data was collected and analyzed. Second, an in vitro Flow-Model analysis was performed comparing the ERIC device® with other stent retrievers for coil retrieval. In 2 cases, the ERIC device® successfully retrieved the displaced coil from intracranial circulation in 1 pass, after failure with other devices. In the Flow-Model, again the ERIC device® achieved success for retrieving a detached coil, whereas 2 other different stent retrievers failed to capture the coil after 2 attempts. The ERIC device® appears to be a safe and effective tool for retrieving a prolapsed or migrated coil from the intracranial circulation. [ABSTRACT FROM AUTHOR]

Patients with COVID-19 may suffer from hemorrhagic complications. Our article highlights two cases of COVID-19-infected patients, who suffered severe epistaxis after initiation of intravenous recombinant tissue plasminogen activator (IV-rtPA) for acute ischemic stroke, followed by a sudden decline in their clinical status and ultimately leading to death within days. Given the global impact and mortality of COVID-19, it is essential to be aware of its unusual presentation and improve therapeutic strategies. We present two cases of individuals who suffered from a large vessel occlusion of and were candidates for both IV-rtPA and mechanical thrombectomy. They received IV-rtPA but had epistaxis so severe that they were not able to receive MT and died within the next few days. There are many potential mechanisms by which epistaxis can happen in an individual with COVID-19 who received IV-rtPA including invasion of the nasal mucosa and endothelium through angiotensin-converting enzyme 2 receptors by the virus. We also hypothesize that the coagulation abnormality seen in COVID-19 patients can be potentiated by the use of treatments such as IV-rtPA. We review these issues with a diagram illustrating the possible mechanisms. [ABSTRACT FROM AUTHOR]

Background Radial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates. Methods An international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature. Results One hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%). Conclusions UETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction. [ABSTRACT FROM AUTHOR]

Flow diverter devices have become a routine first-line option for treatment of an increasing population of intracranial aneurysms at many neurovascular centers. Despite the promising results of flow diverter stents on anterior circulation, incomplete occlusion on the presence of fetal posterior circulation has been described on several reports. Here we describe a novel technical alternative to conventional flow diversion approach for this specific subgroup of aneurysms using the low-profile flow diverter, Silk Vista Baby. The device was selectively placed into the fetal type posterior cerebral artery in half-T configuration for the treatment of a posterior communicating aneurysm using a transcirculation approach through the anterior communicating artery. This represents a useful and effective technique and should be considered when encountering the above-described situation. [ABSTRACT FROM AUTHOR]

A simultaneous arterial and venous approach has been widely described for the endovascular treatment of dural arteriovenous fistula (DAVFs) and recently for arteriovenous malformation (AVMs). Conventional venous approaches are performed by direct internal jugular puncture or by femoral access. Although complication rates are low, there are potential life-threatening complications that should be avoided. The advantages of radial artery access have been widely proven, nevertheless the use of upper limb veins in neurointervention are rarely reported. We present five cases of the simultaneous arteriovenous approach through the radial artery and superficial veins of the forearm for the treatment of intracranial neurovascular diseases. [ABSTRACT FROM AUTHOR]

Endovascular treatment of intracranial aneurysms (IAs) has evolved considerably over the past decades. The technological advances have been driven by the experience that coils fail to completely exclude all IAs from the blood circulation, the need to treat the diseased parent vessel segment leading to the aneurysm formation, and expansion of endovascular therapy to treat more complex IAs. Stents were initially developed to support the placement of coils inside wide neck aneurysms. However, early work on stent-like tubular braided structure led to a more sophisticated construct that then later was coined as a flow diverter (FD) and found its way into clinical application. Although FDs were initially used to treat wide-neck large and giant internal carotid artery aneurysms only amenable to surgical trap with or without a bypass or endovascular vessel sacrifice, its use in other types of IAs and cerebrovascular pathology promptly followed. Lately, we have witnessed an explosion in the application of FDs and subsequently their modifications leading to their ubiquitous use in endovascular therapy. In this review we aim to compile the available FD technology, evaluate the devices' peculiarities from the authors' perspective, and analyze the current literature to support initial and expanded indications, recognizing that this may be outdated soon. [ABSTRACT FROM AUTHOR]

Background The first and second generations of the Pipeline Embolization Device (PED) have been widely adopted for the treatment of intracranial aneurysms (IAs) due to their high associated occlusion rates and low morbidity and mortality. The objective of this study was to evaluate the safety and effectiveness of the third- generation Pipeline Shield device (PED-Shield) for the treatment of IAs. Methods The SHIELD study was a prospective, single-arm, multicenter, post-market, observational study evaluating the PED-Shield device for the treatment of IAs. The primary efficacy endpoint was complete aneurysm occlusion without significant parent artery stenosis or retreatment at 1-year post-procedure and the primary safety endpoint was major stroke in the territory supplied by the treated artery or neurological death. Results Of 205 subjects who consented across 21 sites, 204 subjects with 204 target aneurysms were ultimately treated (mean age 54.8±12.81 years, 81.4% [166/204] female). Technical success (ie, deployment of the PED-Shield) was achieved in 98.0% (200/204) of subjects with a mean number of 1.1±0.34 devices per subject and a single device used in 86.8% (177/204) of subjects. The primary effectiveness endpoint was met in 71.7% (143/200) of subjects while the primary safety endpoint occurred in six (2.9%) subjects, two (1.0%) of which led to neurological death. Conclusions The findings of the SHIELD study support the safety and effectiveness of the PED-Shield for IA treatment, evidenced by high occlusion rates and low rates of neurological complications in the study population. [ABSTRACT FROM AUTHOR]

Purpose: Since appearance of the balloon-remodeling technique and stent-assisted coiling, complex aneurysms have been treated successfully by endovascular means worldwide. Although these two techniques have been widely proven, the combination of both traditionally made the procedures more complicated technically. The aim of our study was to determine the technical success, safety, and efficacy of the low-profile stents delivered through double lumen balloons. Methods: Clinical, procedural, and angiographic data were analyzed. Results: Eighty-four patients (55 women; age range 20–81 years) harboring 86 aneurysms were included in this study. Aneurysm maximal diameter ranged from 2 to 26 mm, with mean 7.5 mm. There were 62 unruptured, 15 recanalized, and 9 acutely ruptured aneurysms. Aneurysm locations were ACoA (31), MCA (36), supraclinoid ICA (4), carotid bifurcation (2), basilar (7), PCA (3), PICA (2), and VA (1). Ninety-three devices were implanted (63 LVIS jr, 15 LEO Baby, 14 ACCLINO Flex and 1 Neuroform Atlas) through the double lumen balloons (Scepter C or XC and Eclipse 2 L). We found 2 minor clinical events (2.4%) and 1 major event (1.2%). Total intra-procedural technical complication rate was 11.6%. Follow-up was available for 71 patients with an average follow-up of 7 months. Complete and near complete occlusion was 90.1%. Residual aneurysms were seen in 9.9%. Conclusion: The "combined remodeling technique" with low-profile stents delivered through double-lumen balloons is technically feasible, safe, and effective for the treatment of intracranial aneurysms. This technique allows the operator to avoid extra maneuvers. [ABSTRACT FROM AUTHOR]

Purpose The aim of our study was to assess the technical success and the safety of this new low-profile flow diverter silk Vista Baby (SVB) by evaluating the intraprocedural and periprocedural complication rate. Material/methods Clinical, procedural, and angiographic data were analyzed. results: 41 consecutive patients (28 women; age average 50.5 years) with 43 aneurysms were treated with sVB. aneurysm sizes were classified by their maximum diameter, with an average size of 9.5 mm (range 2-30 mm). Thirty-four cases were unruptured. five aneurysms previously ruptured, had recurrence after the initial coiling. There were two ruptured cases. aneurysms' locations were: M1 segment (five cases), M2 segment (three cases), M3 segment (one case), middle cerebral artery (MCA) bifurcation (six cases), carotid-T (two cases), anterior communicating artery/A1/A2 (11 cases), pericallosal artery (four cases), supraclinoid ICA (two cases), PCom (one case), V4 segment (three cases), PCA (three cases), SCA (one case), and PICA (one case). We had five intraprocedural complications which resolved without clinical consequences and three events postprocedural events. initial occlusion rates were: eight aneurysms (18.6%) were completely occluded, five aneurysms (11.6%) showed near-complete occlusion, four cases (9.3%) showed incomplete filling, and 26 cases (60.4%) showed persisting filling. The mRS score at discharge from the hospital did not change from the admission mrs score. Conclusion Our study demonstrated that the use of the new low-profile flow diverter, SVB device, for the treatment of intracranial aneurysms is feasible and technically safe. [ABSTRACT FROM AUTHOR]

Purpose The Pipeline Embolization Device (PED) is a routine first-line treatment option for intracranial aneurysms (IAs). The Pipeline Flex Embolization Device with Shield Technology (Pipeline Shield) is an updated version of the PED which has been modified to include a surface phosphorylcholine biocompatible polymer. Its early technical success and safety have been reported previously. Here, we assessed the long-term safety and efficacy of the Pipeline Shield for the treatment of IAs. Materials and methods The Pipeline Flex Embolization Device with Shield Technology (PFLEX) study was a prospective, single-arm, multicenter study for the treatment of unruptured IAs using the Pipeline Shield. The primary endpoint was a major stroke in the territory supplied by the treated artery or neurologic death at 1-year post-procedure. Angiographic outcomes were also assessed by an independent radiology laboratory at 6-months and 1-year. Results Fifty patients (mean age, 53 years; 82% female) with 50 unruptured IAs were treated. Mean aneurysm diameter was 8.82±6.15-mm. Of the target aneurysms, 38/50 (76%) were small (<10-mm), 11/50 (22%) were large (≥10-and<25-mm), and 1/50 (2%) was giant (≥25-mm). Forty-seven (94%) were located in the internal carotid artery and three (6%) in the vertebral artery. At 1-year post-procedure, no major strokes or neurologic deaths were reported, and complete occlusion was achieved in 27/33 (81.8%). There were no instances of aneurysm recurrence or retreatment. Conclusions Our 1-year follow-up concerning angiographic and safety outcomes corroborate previous evidence that the Pipeline Shield is a safe and effective treatment for IAs. [ABSTRACT FROM AUTHOR]

Background The new generation of flow diverters includes a surface modification with a synthetic biocompatible polymer, which makes the device more biocompatible and less thrombogenic. Optical coherence tomography (OCT) can be used to visualize perforators, stent wall apposition, and intra-stent thrombus. Unfortunately real world application of this technology has been limited because of the limited navigability of these devices in the intracranial vessels. In this report, we share our experience of using 3D-printed neurovascular anatomy models to simulate and test the navigability of a commercially available OCT system and to show the application of this device in a patient treated with the new generation of surface modified flow diverters. Material and methods Navigability of OCT catheters was tested in vitro using four different 3D-printed silicone replicas of the intracranial anterior circulation, after the implantation of surface modified devices. Intermediate catheters were used in different tortuous anatomies and positions. After this assessment, we describe the OCT image analysis of a Pipeline Shield for treating an unruptured posterior communicating artery (PCOM) aneurysm. Results Use of intermediate catheters in the 3D-printed replicas was associated with better navigation of the OCT catheters in favorable anatomies but did not help as much in unfavorable anatomies. OCT image analysis of a PCOM aneurysm treated with Pipeline Embolization Device Shield demonstrated areas of unsatisfactory apposition with no thrombus formation. Conclusions OCT improves the understanding of the flow diversion technology. The development of less thrombogenic devices, like the Pipeline Flex with Shield Technology, reinforces the need for intraluminal imaging for neurovascular application. [ABSTRACT FROM AUTHOR]

Direct admission vs. secondary transfer to a comprehensive stroke center for thrombectomy: retrospective analysis of a regional stroke registry with 2797 patients. Higher annual operator volume is associated with better reperfusion rates in stroke patients treated by mechanical thrombectomy: the ETIS registry. In contrast, the complementary German Stroke Registry with many overlapping centers reports clinical outcome data of approximately 90% of the patients (mRS at 90 days) [[14]]. [Extracted from the article]

A 64-year-old female presented with an incidentally-discovered right posterior inferior cerebral artery (PICA) aneurysm, initially treated in 2015 by simple coiling. Follow-up demonstrated significant coil compaction that required retreatment. Retreatment was done uneventfully using a Pipeline embolization device (PED) shield deployed starting from the basilar artery and ending at the V4 segment of the vertebral artery. Eight-weeks post-deployment, a follow-up digital subtraction imaging (DSA) and intravascular imaging with optical coherence tomography were obtained. The intravascular imaging demonstrated that the flow diverter had good wall apposition and concentric neointimal growth over the braid with exception to the areas that the PED was not in contact with the endothelial wall, such as at the right PICA ostium and at the vertebrobasilar junction. The entire procedure was safe, and the patient had no complications. In this article, we describe for the first time the assessment of the status of endothelial "healing" of the PED shield at 8-weeks. [ABSTRACT FROM AUTHOR]

Endoluminal reconstruction with a flow diverter device has emerged as a viable and often preferable alternative to traditional techniques for the treatment of intracranial aneurysms. Precise measurement and device selection are mandatory steps when considering flow diverters usage in order to avoid potential complications. In this sense, incomplete wall-apposition has been described as a predictive factor for immediate in-stent and delayed thrombosis after stent use. One significant usage limitation of flow diverter devices is the parent artery diameter, since the maximum opening of the sizes available are recommended for vessel diameters between 5.2-5.75 mm. Here we present the first clinical use of the largest flow diverter available, the 6×50 mm DERIVO embolization device (Acandis GmbH & Co. KG, Pforzheim, Germany), into the arterial circulation for a cervical internal carotid artery endovascular reconstruction. This is a new device for large or fusiform aneurysms requiring flow diversion, especially located in the vertebrobasilar system or extracranial segments. [ABSTRACT FROM AUTHOR]

Background and purpose The Pipeline Embolization Device (PED) has become a routine first-line option for treatment of intracranial aneurysms (IAs). We assessed the early safety and technical success of a new version of PED, Pipeline Flex Embolization Device with Shield Technology (Pipeline Shield), which has the same design and configuration but has been modified to include a surface synthetic biocompatible polymer. Materials and methods The Pipeline Flex Embolization Device with Shield Technology (PFLEX) study is a prospective, single-arm, multicenter study for the treatment of unruptured IAs using Pipeline Shield. The primary study endpoints included the occurrence of major stroke in the territory supplied by the treated artery or neurologic death at 1 year post-procedure. Secondary endpoints included the rate of Pipeline Shieldrelated or procedure-related serious or non-serious adverse events. Analyses were conducted to evaluate early safety findings in the 30-day post-procedure period as well as technical procedural success outcomes. Results Fifty patients with 50 unruptured target IAs were enrolled. Mean aneurysm diameter was 8.82 ±6.15 mm. Thirty-eight aneurysms (76%) were small (<10 mm). Device deployment was technically successful with 98% of devices. Complete wall apposition was achieved immediately post-procedure in 48 cases (96%). No major strokes or neurologic deaths were reported in the 30-day post-procedure period. Conclusions The results of this first experience with the new Pipeline Flex corroborate the early safety of the device. Mid-term and long-term follow-up examinations will provide data on safety outcomes at the 6-month and 1-year follow-up periods. Clinical trial registration NCT02390037. [ABSTRACT FROM AUTHOR]

The pipeline embolization device (PED) has become a routine firstline option for the treatment of an increasing population of intracranial aneurysms at many neurovascular centers. Intraprocedural complications during PED deployment, or complications associated with migration of the device, are rarely reported problems. Significant mismatch in luminal diameter between the inflow vessel and the outflow vessel or excessive dragging-stretching of the PED have been related to 'watermelon seed' or 'accordion' effects, respectively, resulting in stent migration. Here we present a novel balloon technique that was successfully used to realign an in situ flow diverting stent that had prolapsed into a large aneurysm. This represents a useful salvage technique and should be considered when encountering this potential complication. [ABSTRACT FROM AUTHOR]

Background High-flow craniofacial vascular malformations are uncommon, locally aggressive lesions that pose a therapeutic challenge. Objective To report our experience with the treatment of high-flow craniofacial vascular malformations. Methods After institutional review board approval was obtained, the neurointerventional databases of two institutions were retrospectively reviewed for vascular malformations from October 2010 to June 2015. All patients who had been treated for a high-flow craniofacial vascular malformation were included in the analysis. Clinical presentation, location, type, agent and techniques used, procedural complications, and clinical and imaging follow-up were included in the analysis. Results Eighteen patients (12 female and 6 male) harboring 21 high-flow vascular malformations met the inclusion criteria in our study. All patients were symptomatic. One patient had two separated arteriovenous malformations (AVMs) (one nasal and the other forehead/scalp), and one patient had three separated scalp lesions. One patient with a nasal AVM had capillary malformation-AVM syndrome. Overall, 13 AVM and 8 arteriovenous fistuli were treated in 31 targeted embolization procedures (ranging from 1 procedure to 4 procedures, mean 1.7 procedures). Onyx was the predominant agent used in 25 procedures. In 31 procedures, 1 procedural complication (skin ulceration) occurred. At the end of the last treatment session 14 of the 21 lesions were cured. Symptomatic control was achieved in all cases, with resolution or significant improvement of the symptoms (mean follow-up of 10 months). Conclusions High-flow craniofacial vascular malformations can be successfully managed with interventional techniques. [ABSTRACT FROM AUTHOR]

Objective To describe the treatment of direct high flow carotid-cavernous sinus fistulas (dCCFs) with the double lumen balloon Scepter C. Materials and methods 7 patients with dCCFs were identified and treated with a double lumen balloon Scepter C. 5 patients had post-traumatic dCCFs and two patients had spontaneous dCCFs due to a ruptured cavernous-carotid aneurysm. The double lumen balloon was used in characterizing the angioarchitecture of the fistula in all patients. The best treatment option was then decided based on the characteristics of the carotid wall tear. Embolization of the cavernous sinus was achieved with coils and injection of Onyx liquid embolic material in three patients and with coils alone in four patients. One patient required stent assisted coiling to reconstruct the internal carotid artery. Results 7 patients with dCCFs were treated with transarterial embolization. All patients had immediate angiographic and clinical cure. The Scepter C balloon was used for balloon assisted coiling and injection of Onyx liquid embolic material. On follow-up, all patients had clinical symptom resolution. Conclusions The Scepter C balloon is a useful tool for the transarterial treatment of dCCFs. [ABSTRACT FROM AUTHOR]

Cocaine is a widespread recreational drug that has the potential to induce neurological vascular diseases, including ischaemic and haemorrhagic stroke. Although arterial vasospasm has been suggested as a pathogenic factor in the development of neurovascular complications, it remains unclear whether cocaine users carry an increased risk to suffer iatrogenic vasospasm during endovascular procedures. We report the case of two patients with a history of cocaine abuse, who developed unusual severe vasospasms during different interventional procedures. The first case occurred in a middleaged woman with an unruptured left internal carotid artery bifurcation aneurysm who was scheduled for treatment by remodelling assisted coiling. Just after the placement of the remodelling balloon, a severe occlusive vasospasm interrupted the procedure. The second case happened to a 46-year-old man with a non-aneurysmal subarachnoid haemorrhage and a symptomatic vasospasm in the right-sided anterior circulation who developed another occlusive vasospasm after the first attempt at transluminal balloon angioplasty. Further research is needed to establish a relation between cocaine use and increased risk of iatrogenic vasospasm in endovascular procedures, but we suggest practitioners be extremely cautious when treating this subgroup of patients. [ABSTRACT FROM AUTHOR]

Intracranial dural arteriovenous fi stulas with retrograde leptomeningeal or cortical drainage are considered aggressive. Conventional treatment in these cases is possible surgically or with endovascular arterial injections of Onyx or cyanoacrylate, but there are still some cases where distal navigation is not possible due to tortuosity of the arterial feeders. We present fi ve cases of direct transforaminal Onyx embolization where endovascular distal navigation could not be achieved. [ABSTRACT FROM AUTHOR]

Purely extradural lumbar spinal arteriovenous malformations (AVMs) are rare lesions that have diverse presentations and imaging features. The treatment of a symptomatic high flow paraspinal AVM with multiple feeders remains a challenge. We report the first use of an Ascent balloon (dual lumen balloon catheter) to deliver Onyx with excellent penetration to a paraspinal AVM. [ABSTRACT FROM AUTHOR]

Cerebral arteriovenous malformations (AVMs) are uncommon. Treatment options include embolization, radiosurgery and surgery, separately or combined, the final goal being complete occlusion of the malformation. We describe the case of a symptomatic small subependymal AVM with a single deep drainage vein previously treated unsuccessfully by radiosurgery and transarterial embolization. The AVM was successfully embolized transvenously using Onyx, achieving complete occlusion in a single treatment session. [ABSTRACT FROM AUTHOR]

We aimed to study the relationship between the ischemic core's (IC) radiological hypodensity and the risk of parenchymal haematoma after endovascular therapy (EVT) in acute ischemic stroke (AIS) presenting > 4.5 h from onset. We studied AIS patients with a proximal anterior circulation occlusion > 4.5 h from symptoms onset treated with primary EVT. The IC regions of interest (ROI) were manually delineated on pretreatment CT within the affected hemisphere and their specular ROIs on the unaffected side. IC hypodensity ratio was calculated by dividing mean Hounsfield Unit (HU) value from all ROIs in affected/unaffected hemisphere. Primary endpoint: parenchymal hematoma (PH) type hemorrhagic transformation. Secondary: poor long-term clinical outcome. From May 2015 to November 2018, 648 consecutive AIS patients received reperfusion therapies and 107 met all inclusion criteria. PH after EVT was diagnosed in 33 (31%) patients. In bivariate analyses, IC hypodensity ratio (p < 0.001) and minimum HU value (p = 0.008) were associated with PH. A lower IC hypodensity ratio [OR < 0.001 (< 0.001–0.116) p 0.016] predicted PH but not poor clinical outcome in multivariable logistic regression models. A lower IC radiological density predicted a higher risk of PH in > 4.5 h-window AIS patients treated with primary EVT, although it was not independently associated with a worse clinical outcome. [ABSTRACT FROM AUTHOR]